Multi-Tier Enhanced Drug List Updates July 2021

Brand/Generic TRADE NAME (generic name) or generic name Product Description of Change AFINITOR (everolimus tab 10 mg) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 100 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 200 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 25 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 300 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 40 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln inj 60 mcg/ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml) Brand Addition ARANESP ALBUMIN FREE (darbepoetin alfa soln prefilled syringe 500 mcg/ml) Brand Addition ATRIPLA (efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg) Brand Removal, generics available AZITHROMYCIN (azithromycin powd pack for susp 1 gm) Brand Addition CARBAGLU (carglumic acid tab 200 mg) Brand Addition COMBIVENT RESPIMAT (ipratropium-albuterol inhal aerosol soln 20-100 mcg/act) Brand Addition COTELLIC (cobimetinib fumarate tab 20 mg (base equivalent)) Brand Addition CRINONE (progesterone vaginal gel 4%) Brand Addition CRINONE (progesterone vaginal gel 8%) Brand Addition DILANTIN (phenytoin sodium extended cap 30 mg) Brand Addition EMCYT (estramustine phosphate sodium cap 140 mg) Brand Addition KESIMPTA (ofatumumab soln auto-injector 20 mg/0.4ml) Brand Addition LATUDA (lurasidone hcl tab 120 mg) Brand Addition LATUDA (lurasidone hcl tab 20 mg) Brand Addition LATUDA (lurasidone hcl tab 40 mg) Brand Addition LATUDA (lurasidone hcl tab 60 mg) Brand Addition LATUDA (lurasidone hcl tab 80 mg) Brand Addition LOTEMAX (loteprednol etabonate ophth oint 0.5%) Brand Addition LOTEMAX SM (loteprednol etabonate ophth gel 0.38%) Brand Addition LUMIGAN (bimatoprost ophth soln 0.01%) Brand Addition MAYZENT STARTER PACK (siponimod fumarate tab 0.25 mg (12) starter pack) Brand Addition MESNEX (mesna tab 400 mg) Brand Addition MULTAQ (dronedarone hcl tab 400 mg (base equivalent)) Brand Addition NEULASTA (pegfilgrastim soln prefilled syringe 6 mg/0.6ml) Brand Addition NEULASTA ONPRO KIT (pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml) Brand Addition NEXIUM (esomeprazole magnesium for delayed release susp pack 2.5 mg) Brand Addition NEXIUM (esomeprazole magnesium for delayed release susp packet 5 mg) Brand Addition norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) Generic Removal NYVEPRIA (pegfilgrastim-apgf soln prefilled syringe 6 mg/0.6ml) Brand Addition OZEMPIC (semaglutide soln pen-inj 1 mg/dose (4 mg/3ml)) Brand Addition PLEGRIDY (peginterferon beta-1a im soln prefilled syr 125 mcg/0.5ml) Brand Addition PREDNISOLONE SODIUM PHOSPHATE (prednisolone sodium phosphate ophth soln 1%) Brand Addition

Continued

July 2021 | Multi-Tier Enhanced Drug List Updates Brand/Generic TRADE NAME (generic name) or generic name Product Description of Change PREDNISONE (prednisone oral soln 5 mg/5ml) Brand Addition PRENATAL 19 (*prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg***) Brand Addition PRENATAL 19 (*prenatal vit w/ fe fumarate-fa chew tab 29-1 mg***) Brand Addition PROPRANOLOL HCL (propranolol hcl oral soln 20 mg/5ml) Brand Addition PROPRANOLOL HCL (propranolol hcl oral soln 40 mg/5ml) Brand Addition PURIXAN (mercaptopurine susp 2000 mg/100ml (20 mg/ml)) Brand Addition REDITREX (methotrexate soln prefilled syringe 10 mg/0.4ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 12.5 mg/0.5ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 15 mg/0.6ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 17.5 mg/0.7ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 20 mg/0.8ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 22.5 mg/0.9ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 25 mg/ml) Brand Addition REDITREX (methotrexate soln prefilled syringe 7.5 mg/0.3ml) Brand Addition SE-NATAL 19 (*prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg***) Brand Addition SE-NATAL 19 (*prenatal vit w/ fe fumarate-fa chew tab 29-1 mg***) Brand Addition SIMBRINZA (brinzolamide-brimonidine tartrate ophth susp 1-0.2%) Brand Addition SYNJARDY (empagliflozin-metformin hcl tab 12.5-1000 mg) Brand Addition SYNJARDY (empagliflozin-metformin hcl tab 12.5-500 mg) Brand Addition SYNJARDY (empagliflozin-metformin hcl tab 5-1000 mg) Brand Addition SYNJARDY (empagliflozin-metformin hcl tab 5-500 mg) Brand Addition SYNJARDY XR (empagliflozin-metformin hcl tab er 24hr 10-1000 mg) Brand Addition SYNJARDY XR (empagliflozin-metformin hcl tab er 24hr 12.5-1000 mg) Brand Addition SYNJARDY XR (empagliflozin-metformin hcl tab er 24hr 25-1000 mg) Brand Addition SYNJARDY XR (empagliflozin-metformin hcl tab er 24hr 5-1000 mg) Brand Addition TABLOID (thioguanine tab 40 mg) Brand Addition TRUVADA (emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg) Brand Removal, generics available TRUVADA (emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg) Brand Removal, generics available TRUVADA (emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg) Brand Removal, generics available TRUVADA (emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg) Brand Removal, generics available VELPHORO (sucroferric oxyhydroxide chew tab 500 mg) Brand Addition VIMPAT (lacosamide oral solution 10 mg/ml) Brand Addition VIMPAT (lacosamide tab 100 mg) Brand Addition VIMPAT (lacosamide tab 150 mg) Brand Addition VIMPAT (lacosamide tab 200 mg) Brand Addition VIMPAT (lacosamide tab 50 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 10 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 20 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 30 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 40 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 50 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 60 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate cap 70 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate chew tab 10 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate chew tab 20 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate chew tab 30 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate chew tab 40 mg) Brand Addition VYVANSE (lisdexamfetamine dimesylate chew tab 50 mg) Brand Addition

Continued

July 2021 | Multi-Tier Enhanced Drug List Updates Brand/Generic TRADE NAME (generic name) or generic name Product Description of Change VYVANSE (lisdexamfetamine dimesylate chew tab 60 mg) Brand Addition XELJANZ (tofacitinib citrate oral soln 1 mg/ml (base equivalent)) Brand Addition XTANDI (enzalutamide tab 40 mg) Brand Addition XTANDI (enzalutamide tab 80 mg) Brand Addition ZOKINVY (lonafarnib cap 50 mg) Brand Addition ZOKINVY (lonafarnib cap 75 mg) Brand Addition ZYLET (loteprednol etabonate-tobramycin ophth susp 0.5-0.3%) Brand Addition

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